Senin, 18 Desember 2017

Mandatory Parent Counseling Can Reduce Vaccine Exemptions

Mandatory Parent Counseling Can Reduce Vaccine Exemptions


Vaccine exemption rates in Washington State saw a significant relative decrease of 40% after 2011 legislation required parents to get counseling and/or a signature from a licensed healthcare provider to receive an exemption, according to a new study.

Saad B. Omer, MBBS, MPH, PhD, from the Hubert Department of Global Health, Department of Epidemiology, Department of Pediatrics, and Emory Vaccine Center at Emory University in Atlanta, Georgia, and colleagues report their findings in an article published online December 18 in Pediatrics.

The researchers evaluated how implementing Senate Bill 5005 (SB5005) affected vaccine exemptions across the state. They studied coverage and exemption rates before and after the law during Washington’s school years 1997 to 1998 through 2013 to 2014.

Along with the relative decrease of 40.2% in exemption rates (95% confidence interval, −43.6% to −36.6%), they found a significant absolute reduction of 2.9 percentage points (95% confidence interval, −4.2% to −1.7%) in immunization exemption rates at the state level.

The investigators also found an increase in vaccine coverage for all vaccines that are required to enter school except the hepatitis B vaccine. The law also was linked to a decrease in geographic clusters of people with exemptions. They say this study is the first to evaluate the effect of a law mandating counseling on exemptions.

“This highlights the importance of more stringent polices for obtaining immunization exemptions,” the authors write.

Authors looked for a potential backfire effect from the counseling sessions, which discussed the benefits and risks for vaccines, but found the counseling was not linked to an increase in exemptions or decrease in vaccinations.

States Vary Widely on Exemptions

Although all states and Washington, DC, offer medical exemptions from mandated vaccines, the rules differ widely on personal and religious belief exemptions. Eighteen states allow religious and personal belief exemptions; 29 states and Washington, DC, allow religious, but not personal, belief exemptions; and three states allow no exemptions other than medical.

Evidence from this study that adding a counseling requirement may be effective in reducing exemptions may inform policy in other states, the authors write.

California is one of the three states (joining Mississippi and West Virginia) with medical-only exemptions. The California law was implemented for the 2016 to 2017 school year.

Richard J. Pan, MD, MPH, a California state senator and pediatrician, writes in an accompanying commentary that SB5005 was the model for the 2012 bill he authored in California, AB2109. After implementation, the law reduced nonmedical exemptions for the first time in more than 10 years from 3.15% to 2.5% in 1 year, but did not restore community immunity, he notes, as witnessed by the outbreak of measles originating at Disneyland in 2015 that spread across the state.

Parents wanted change in the wake of the outbreak, Dr Pan writes, and he authored SB27, which abolished nonmedical exemptions.

A tougher legislative approach is needed, he says, because parents have been confused by antivaccine messages from powerful lobbying groups that make educational efforts increasingly difficult.

“[I]t is difficult to change behavior in people exposed to vaccine misinformation, as is indicated in vaccine hesitancy research,” he writes.

During the first year after implementation, California’s kindergarten class achieved a 96% vaccination rate, he writes with a combination of the legal backing, education, and public awareness efforts.

Dr Pan also acknowledges he has heard reports of physicians profiting from selling medical exemptions, a practice he says should draw sanctions from professional boards.

Part of the path to raising community immunity must come from physicians, Dr Pan writes.

“Most importantly, pediatricians need to build the political will to pass effective vaccine policy. Antivaccine groups are organized and well funded, and they resort to intimidation and threats to suppress proscience advocacy on social media and in legislatures,” he says.

The authors acknowledge limitations of the study, including lack of a control group and analysis from only one state.

“Therefore, this type of analysis will have to be repeated for other states with recent changes in vaccine laws as their postchange data become available,” they write.

The study was funded by a grant from the Robert Wood Johnson Foundation. One coauthor was a consultant for Merck and conducted sponsored research for Crucell and Pfizer. Another coauthor’s organization, Association for Immunization Managers, receives unrestricted funding from 21 corporate entities, including vaccine manufacturers. Dr Pan authored legislation to modify (AB2109) and abolish (SB277) nonmedical exemptions.

Pediatrics. Published online December 18, 2017. Article full text, Commentary full text

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